DEPARTMENT OF EMERGENCY MEDICINE OBSERVATION MANUAL. Directory. Adapted from Emory University CDU Protocols
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1 DEPARTMENT OF EMERGENCY MEDICINE OBSERVATION MANUAL Directory Version 11-13b Adapted from Emory University CDU Protocols
2 Protocol Directory General Guidelines Protocols: Abdominal Pain Allergic Reac6on Asthma Atrial Fibrilla6on Back Pain Celluli6s Chest Pain COPD Exacerba6on Dehydra6on/Vomi6ng/Diarrhea Drug/Alcohol Inges6on DVT Head Injury Headache Hyperglycemia Hypertensive Urgency Hypoglycemia Pneumonia Pyelonephri6s Renal Colic Seizure Social SVT Syncope Transfusion Vaginal Bleeding Ver6go Title Page Credits
3 OBSERVATION MEDICINE Definition Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. - Medicare Policy Manual Next Page
4 OBSERVATION MEDICINE General Guidelines Active management of patients following their initial ED care to determine the need for inpatient admission Maximum length of stay <24 hours (optimally <18 hours) ED attending ensures suitability for observation status Next Page
5 OBSERVATION MEDICINE Focused Goals Diagnostic evaluation of critical symptom i.e. chest pain, syncope, abdominal pain, etc. Short term treatment of an emergency condition i.e. asthma, dehydration, cellulitis, headache, COPD, etc. Management of psychosocial needs and ensuring follow up care i.e. need for home support services, placement or social services assistance Next Page
6 OBSERVATION MEDICINE Patient Characteristics Limited intensity of service and severity of illness At least 70% probability of discharge in <18 hours if managed effectively Relatively low severity of illness/complexity Necessary resources and level of care available in the ED/CDU Next Page
7 OBSERVATION MEDICINE Documentation Observation time begins at the clock time documented in the patient s medical record, which coincides with the time that observation care is initiated in accordance with a physician s order. The [patient] must be in the care of a physician during the period of observation, as documented in the medical record by outpatient registration, discharge, and other appropriate progress notes that are timed, written, and signed by the physician. The medical record must include documentation that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care. - Medicare Policy Manual
8 ABDOMINAL PAIN OBSERVATION PROTOCOL
9 ALLERGIC REACTION OBSERVATION PROTOCOL
10 ASTHMA OBSERVATION PROTOCOL
11 ATRIAL FIBRILLATION OBSERVATION PROTOCOL 1/2 Next Page
12 ATRIAL FIBRILLATION OBSERVATION PROTOCOL 2/2
13 BACK PAIN OBSERVATION PROTOCOL
14 CELLULITIS OBSERVATION PROTOCOL
15 CHEST PAIN OBSERVATION PROTOCOL
16 COPD EXACERBATION OBSERVATION PROTOCOL
17 DEHYDRATION/VOMIT/DIARRHEA OBS PROTOCOL
18 DRUG/ALCOHOL INGESTION OBS PROTOCOL
19 DVT OBSERVATION PROTOCOL
20 HEAD INJURY OBSERVATION PROTOCOL
21 HEADACHE OBSERVATION PROTOCOL
22 HYPERGLYCEMIA OBSERVATION PROTOCOL
23 HYPERTENSIVE URGENCY OBSERVATION PROTOCOL
24 HYPOGLYCEMIA OBSERVATION PROTOCOL
25 PNEUMONIA OBSERVATION PROTOCOL
26 PYELONEPHRITIS OBSERVATION PROTOCOL
27 RENAL COLIC OBSERVATION PROTOCOL
28 SEIZURE OBSERVATION PROTOCOL
29 SOCIAL OBSERVATION PROTOCOL
30 SVT OBSERVATION PROTOCOL
31 SYNCOPE OBSERVATION PROTOCOL
32 TRANSFUSION OBSERVATION PROTOCOL
33 VAGINAL BLEEDING OBSERVATION PROTOCOL
34 VERTIGO OBSERVATION PROTOCOL
35 Credits Protocols and Guidelines adapted from the Emory University School of Medicine, Department of Emergency Medicine, Clinical Decision Unit Manual 2012, Michael Ross, et al
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